A29 222FROM :PERSON COUNTY COURT S7 Gi]V C[XM FAX NQ. :336 S97 1799 Jul. 31 2002 09:02�1 P1
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'tl Psrmit r�qtMa�i : tOw��l�dpr�ap�cMv� owrNrj� � � 1U�,5
Hom! Pftone: � �� Addre�e: ' � ,
Budnese Phata o U
� N� and act�nra vf aan+ar! vwn�� ��es !
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a� fzz� � r�c, 13'l'�'�...,
3) ProPw'�l p+�rll�w�: l.ot slzo: , 5� Towttah(p: �liJc ' $ubdfvi�ion:
Dh�eattartif tc the prapertY i�nciudlrg wad nemes �nd numbers): –.__ /,J
Lot #
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4} propoNd tJs�r and gt�twRur+� p,pie�Ipqpn: anawe� e�t o�( tt�e tdtaMnfl questlana: .
�� �P'�� .-,� �Ci�n�i � TYPe o! 3truattxe: Wfdth�� Depth:!1.0
b) Numba► af �clronme: :� Numt�er ol occupants or people to b� s�rwd: L —
a) 8�ae�t�rrt: Ye� , No ,�, Wili there be pturnbin� In the bes�ment?
d) �blg� I�laposal: Yds �,. No .�
3) wa�r �u1+PA► TYp�: PrMate �/ (n�w ,_,,,; ar axtttlnp,_,�, Publio . CommuNtyr , spiirsg _
Are arry vw�its a�► adjoinlnp property? Yeg Na � 1! yas, ploase indlcate approacimal� tocatkari an �ai�ic:�
��te pWn.
� Qo�s your prop�r�y oontsi��pr�vbuNy td�ntl�! ju����,�1 w�tl�nds? Yu,.� No ✓
PLEd�.NS��'S.7�i�kQLLOWING:
>�► Pl.X'f' 4F'THE PROl�'lRTY OR �1'iE RLAN MUlfT BB BUBMTTED Nf1TH THI8 Ap��.lC/►TION.
A PI�OPERt'Y LMIE9 ANk1 CORNQRB MU9T !!C C�EARLY MARKED. '
�' Ttf� pllClPd� tOCAT10M t?F At.1, 9'1'RUCTUREB MUBT 8E BTAKED OR FL/1Qti�D.
A'i'N� St'�: �Atl�T � RE�101LY ACCE�181.E FOI� AN EVAI,UATt1�N BY THE HEALTN D�RARTMF�Ni
9TJ1l�l�.
! henby make spplicat}ort to the Pnraon County Nealih D�pa�tment ficr � slt� avalu�tfon for the on-site aewa�}e di�p��sal
ayst�m ior ihe above�de�aribed property, I aqrea that !he contanie of thls apptkation au+s true and repreeent th� m��:i�•�,um
facilltles to be �d on th� property, I undbr�tand it ths slte ta altered or the tntgndsd uee changes, the ��errrali ::�hail
becam� trnaitd.
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Date
PCHrr, �ev. +� tr���roz
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Applicanl
Location:
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Tax Ma� �r P�rcel # ��d
S'Ulh C�II V I�*S I 0 tl
Fh�se Sect�ion Lot #
Permit Valid for �Five Years
Type of Facility: �,,� <
# of Occupants � # of Be�
Proposed Wastewater System: �
Proposed Repair: L--� �
Permit Conditions:
�
Improvement Permit
No Expiration
� New 1/Addition Water Supply �_ _l�__ii`�.�.
s� Projected Daily Flow 3(�� g.p.d. �
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�n�� �.�11� ��''1`���'�! Type: �.i�
Type: _���;.r
Owner or Legal Representative Signature:
Authorized State Agent:
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The issuance of this permit by the I-�'leJalth Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicanbproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and
Rules for Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain
potable.
Authorization to Construct Wastewater System (Required for Building Permit)
* See site plan and additional attachments (_).
Proposed astewater System: S ��c�V� �\�1,i-�1'� Type� Was �water Flow ��.p.d.
New � Repair Expansion _ Soil LTAR: • a`� .J g.p.d./ ft 2
Type of Facility: 3�j�- �� Basement _ Yes �/No .
Wastewater System Requirements
Tank Size: Septic Tank: _�� gal Pump Tank: N� gal Grease Trap: �� gal
Drainfield: Total Area: � y'7U sq ft Total Length _C ft Mazimum Trench Depth / in
Trench Width J� ft Minimum Soil Cover: � in Minimum Trench Separation: ft
Distribution: Distribution Box ✓Serial Distribution Pressure Manifold
Specifications:
Authorized State Agent:
Pennit Exr
The type of system permitted is
the permit. `'
Owner/Legal Representative: ,7�
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Date: � � O �� �
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Innovative Alternative. I accept the specifications of
Date: � -��� 3
PCHD8/28/2002
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Name �� � �'U e � .
S division
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Autho�ized Sta.te gent
SI'�. S�'I'��.
Tas lYtap #�Pascel #.����
Section/Lot#
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Date
System cnmponents represent appro.�imate�contours only. The contractor 9nust, flag the syste�n praor to
beaainning tdte installation io insure thatproperbarade is maintained
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Scale: � �sC�ti
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� NC 49 100
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R/W
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WELL PERMIT
PLEASE SEE A2"I'ACHED PLAN FOR WELL SITE LAYOU']C
Tax Map #: � Parcel # � � � T ship �J I � � e' [ � ' I 1
Applicant:
Subdivision:
T�e of Water Su��ly:
Rec�uirements•
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Section: Lot:
��c -�-��-, � ti`��'�
✓�vidual Community Public
Site Approved by �
Grouting Approve p l� Z��° 3
Well Lo �
g
Well T C�S s -»-��I
Air Vent. C53 s-►�-�U
Hose Bib � C,� 5-i�-�y
Concrete Slab �C.� y-��-�� � �S ���-
Well Driller. G��t-S
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Well Approved By� Date: �-���'`�
'�°5ee Attached Site Sketch'�°k
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from anp building foundation.
Other conditions:
PCHD, rev. 09/07/01
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IE������.��m.��.Ti IE-33L��.IL�1� �0 �� / o-� 3- ��
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Owner..�
Location: _�
Subdivision:
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Well Log
Lot #
Tax Map� Parcel # �
Well Construction
Distance From nearest Property Line (Minimum 10 feet) v
Distance from Septic System (Minimum 60 feet) c�-
Tota1 Depth: )� � ft Yield: � GPM Static Water Level: � ft
Water Bearing Zones: Depth /38' ft��s ft ft ft
Casing: .
Depth: From _� to j a�1 $. Diameter: d� in
Type: Galvanized Steel �'
Weight•�_ Thickness: l 8" � Height above Grounci: � in •
Drive Shoe: ✓Yes No Any problems encountered while setting casing? Yes
If "yes" give reason:
Grout:
Neat: SandlCement c/ Concrete Gra.veUCement
Annular Space Width inches Water in Annular Space Yes
Method of Grout: Pumped Pressure Poured Depth
Materials Used:
No. Bags Portland cement Weight of 1 Bag � Pounds •
If mixture (sand, gravel, cuttings) — Ratio _� to 1
ID plates: �es _ No 4 x 4 slab �'Yes _ No
_ No
_ No
to Ft.
Drilling Log � Location Drawing
From 'To Formation
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I hereby certify that the above information is correct and that this well was constructed in accordance with regulations
set forth by the Person County Health Department.
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Signature of Contractor Q� /jv �%i°„� ID�'# o�3c� Date % a-� S�� �3
PCHD rev O1/16/02
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Applica�
Location: �
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S'll'h C�!i V 15'{'Oil
P�h:�:se��Sec�t�i�a�� �L.at =
� System Type (In Acco,rdance With Table Va): � �
THtS SYSTEM 9�iAS BEEA1 INSTALLEi3 lid COMPLlANCE 1l�ITH APPL,lCA�i..� NOR7ir9
CAROLdAIA GENER�►L. STATUTES,. RULES .�Od2 SEWAGE� �TFt�AiMENT �1iVD� �DISPOSAL,
AND AL.L CONDITiO1dS OF THE IAAPfaOV�ririflENT ' PE�IT . AIdD CONSTRUCTiORd
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Autho 'zed S ie �Agent . • . , • . � . . . . : . Date � - . . .
a- . � • • . . . .
Installed By. J'v�-Y,,-� �,,,,,'s. Date: �-a3-�f �
. . . 11-10-c:�3 . . . . . .. . • • . . ' . . . "_� . d'� . �
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r C�tD, rev. G7/29/G2
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s��c� z��� i�����-�t�� c�t���s� (���� i- nr�
Ta : Map #� Parce! #�a� System Type (Tabie Va) Ct �
Owme�lApQlicant �� � Subdivision
Address/Location � � � C� �, Se�lPhase Lnt #
� � �� 3 . � � �
. Septic Tand� n a�� c�on nes n��e
St�te ID/date � :.�� �1 .�- T�nch Wid#h 3 ft. � a a3-�
Capaciiy. -��, . gal. �✓ a-a Trencf�. De th I 8 rn. ��� �y
Tee and Flier Trench.Length yq� ft. � a�-
Bafiie Trench Grade � a �-
� Sealarrt a-a3-�./ Trench S acin �
� Riser iF a(icable ✓'� �23-� Rodc De th and. Qualiiy y�
Tank Ou�et:Seai ✓c,-� ��a3-�y Dams/Ste owns etc. � -�,a3--v
Permanerit Marker , � �-vU Pressure Laterats
� : Pt�np �Tank � Hole Spar,ing .
. tate e � � o. e� ize �� - � . � � � � .
. Capacity . ai. ' t� Pipe Sieeve . � - - � � �
Wate roofi /Sealarrt � Tum-ups}Protectors • � � �
� Riser . � �6�equiresd Se�ac�s
Vllaier Tighi . � � From Wells •. � �
. . Pu�p � From Property lines .
�� �beck ValvelGate Vafve . ._� .Structures/Basemerrts.:_ � �.�
� ip on o e � - � rt es - rainage � ays- �-g�
• Fioats/�witches � : . � � . . � . . . _ : . �SurFace` Waters . . . _
. Alarm (visable and audible) \Q` Pubiic Water Supplies -c� .
Rate f9Pm)
Appr�oved Pump Modei
� -
BlociC Under Pump
Pump Removal Rope/Chain
�i]isici6ution Sysfiem
Seria! Distribution '�
ressure an' o
Low Pressure Pipe •
Aoar. Pioe Materiai and Geade
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Vertical Cuts (>2 ft.)
Water Lines
Vehicle Traf�ic -
Easeme�rtslRight of 1tV�
�e�_
Easemerrts Recorded .
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pchd rev. 3I13101
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